Will Americans ever love Obamacare?

All through the Obama years, backers of the Affordable Care Act have lifted their spirits with a consistent refrain: Just you wait.

Someday, the law's backers insisted, Obamacare will make the transition from a divisive idea to a widely popular one, from a program that many people still find confusing and scary to a familiar and comforting part of American life.

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This weekend, which marks the third anniversary of the law’s passage, one thing remains clear: Someday has not yet arrived, and may not for a long time.

Even as the pitched ideological and legal battles have faded, a huge raft of complicated and potentially crippling practical challenges remain, raising questions about whether Obamacare ultimately will work and whether it will become the Rushmore-size achievement that President Barack Obama hopes for.

Even the law’s most enthusiastic backers concede the path forward is difficult.

“Sure, things aren’t going to be perfectly efficient the first day,” said Jay Angoff, a health care consultant who formerly ran the federal exchange office and who still remains optimistic that kinks will be worked out.

Here are five challenges that still confront the Affordable Care Act, even three years after it became the law of the land:

The money chase

The federal role in building the health insurance exchanges is bigger than expected — and money wasn’t set aside.

The Obama administration didn’t expect 33 states to refuse to build their own health insurance exchanges. When it asked Congress for another $1 billion for implementation, including money for the feds to build exchanges, the Republicans did not cut a check — and Democrats didn’t push much. The IRS didn’t have better luck asking for another $360 million for work on Obamacare tax provisions.

That’s a problem because although the law provides ample funding for state exchanges, it slotted just $1 billion for the feds to make it work. HHS hasn’t responded to questions from POLITICO about how much, if any, of that $1 billion is left or precisely how it’s cobbling together the rest of the money it needs to finish the job.

HHS keeps saying everything’s on track, but some Democrats are openly worried about how to pay for things like vastly complicated computer systems.

“Without IT infrastructure to process enrollments and payments, verify eligibility and establish call centers, health insurance for millions of Americans could be further delayed,” Rep. Nita Lowey (D-N.Y.), the top Democrat on the House Appropriations Committee, said in a recent floor speech criticizing the House for not ponying up more money.

Critics say the money problems could spell trouble.

“The massive uncertainty around their ability to pull this off is causing real problems,” said James Capretta, a vocal Obamacare critic and former budget official under President George W. Bush.

The law’s advocates maintain HHS will get the job done.

“The most important thing about a successful executive branch initiative, much more important than the funding even, is having the president’s full commitment,” said Chris Jennings, a top health care adviser in the Clinton administration. “And this administration has left no doubt about that.”

Getting the word out

From now until enrollment opens in October, messaging matters.

Obamacare won’t work if people don’t sign up for coverage. But they won’t sign up if they don’t know how to enroll, how it may help them or precisely what — after three years of fuss — they are signing up for.

Obama’s new grass-roots arm, Organizing for Action, is gearing up for a political campaign-style effort to boost enrollment. The Obama administration itself is planning a multimillion-dollar PR push closer to the Oct. 1 start of open enrollment. States running their own exchanges are also lining up PR campaigns to get the word out, and various advocacy groups are pitching in.

They’re also likely to get some help from health care organizations that stand to bring in millions of new customers. Hospitals and insurers — who have the most to gain from having millions of more people insured — will push the enrollment message.

Andrew Sussman, president of CVS Caremark’s MinuteClinic arm, said the company is thinking about how it could inform customers.

“We think there is an opportunity for us to educate people with a very kind of high-level specific set of bullets that are germane no matter what their personal situation is,” Sussman said.

Counter-message: A slice of pizza with Obamacare

The anti-Obamacare drumbeat isn’t going away.

Inside the Beltway, Republicans verbally batter the law as an irresponsibly expensive government takeover of health care that will drive up costs for everyone. Minnesota Rep. Michele Bachmann went even further in her three-year anniversary outburst, saying it will “kill” people.

Pizza chains, burger joints and restaurant chains have been particularly vocal, saying that the financial burdens of Obamacare will cost jobs and add to the price of every mouthful.

Insurers' and business groups' warnings about “premium shock” — the possibility of big insurance price hikes — may deter people from signing up. And if everyone stays home, Obamacare stumbles.

Supporters of the law are already warning that there will be bumps to smooth out, that some state exchanges may work better than others. But if the rollout is rocky, expect reinvigorated foes of the health law to try to swoop in and sweep aside the wreckage in the 2014 congressional elections.

The rogue states

Conservative states are trying to balance their distaste for the law with their recognition that it’s moving ahead.

The conventional wisdom in 2012 was that the defeat at the Supreme Court and the November elections would lead many anti-Obamacare states to accept the inevitable and try to shape the law on their own terms to the degree possible. And once again, the CW was wrong.

A few GOP governors are working with the feds on exchanges, and several — including big-name Republicans like Rick Scott of Florida and Chris Christie of New Jersey — back the optional Medicaid expansion.

Just 17 states and Washington, D.C., have received the preliminary OK to run their own exchanges. That means the feds will have to step in and build exchanges in at least 33 states, including seven states that will “partner” with HHS. And that doesn’t count any states that won’t have their own exchanges ready, even if that was their intent.

State legislatures are still the wild card. Some Republican-controlled legislatures are fighting back against GOP governors who are breaking party orthodoxy to support Medicaid expansion. Elsewhere, as in Texas, it’s the GOP state lawmakers who are pushing their governors toward expansion.

But even the most recalcitrant states — states that say they won’t even enforce new federal insurance laws — aren’t quite mounting a full-scale mutiny against the health law. They won’t run the show, but they aren’t blocking Washington from stepping in.

As Alan Weil, executive director of the National Academy for State Health Policy, summed it up: “I don’t see sabotage.”

A tough build-out

The insurance networks require sophisticated new technology with many moving parts and a great deal of coordination among government agencies.

All the political and legal squabbling about Obamacare drained time, money and energy. Now, the administration has just months left to set up the exchanges and finish a mammoth multi-agency “data hub” that is supposed to instantly determine who gets subsidized insurance or Medicaid. Jennings said another priority is launching a call center to help millions of people — already confused by the sprawling law — to navigate their new health care options.

The hardest piece is the cyber architecture connecting a slew of federal agencies to one another, the states and consumers, said Angoff, the former health reform official.

The idea is sort of like Travelocity — but health insurance, of course, is more complicated than plane tickets. The consumer provides basic information about age, location, family size and tobacco use, and the “hub” kicks in data about the applicant’s citizenship, income and employment. All of that is supposed to generate information about eligibility, subsidies and net costs for various health plan options.

On Day One, it won’t be “seamless,” as advocates put it. But how far off course, what pieces of the law, if any, could be delayed, is unknown. HHS officials have said they’re whipping up contingency plans — secret, at least for now. Naturally, they hope they’re never needed.

Gary Cohen, who heads the HHS exchange office, spoke about the law at an insurance conference last week and summed it up this way: “As we move closer to October, my hope certainly would be that the range of things that could go wrong gets narrower and narrower.”

This article first appeared on POLITICO Pro at 8:43 p.m. on March 21, 2013.